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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850385
Report Date: 07/10/2025
Date Signed: 07/10/2025 08:00:16 PM

Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARE OF HEARTFACILITY NUMBER:
195850385
ADMINISTRATOR/
DIRECTOR:		SARGSYAN, MAYAFACILITY TYPE:
740
ADDRESS:14625 LEADWELL STREETTELEPHONE:
(818) 983-7224
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
07/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Marina Martirosian, StaffTIME VISIT/
INSPECTION COMPLETED:
08:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Yee and Martha Arroyo conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 01/27/2025. Upon arrival, there was one (1) staff and four (4) residents present. The LPAs met with staff, Marina Martirosian, and explained the reason for the visit. The LPAs contacted the Licensee Representative, Alexander Otiashvili via telephone and were informed that they were unavailable to join in today’s visit. Entrance interview.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety concerns. The power has been restored to the facility as of 07/09/2025. No immediate safety concerns were observed during today’s inspection. The following was observed during the plant tour:

KITCHEN: The LPAs inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Staff stated they plan on going grocery shopping within the next few days.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be new with a purchase date of 01/26/2025. The LPAs observed required postings throughout the common space.

RESTROOMS: There is one (1) restroom by the main hallway for resident use, which was clean and sanitary and in operating condition with grab bars and non-skid surfaces.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files reviewed, there is no evidence that the staff or volunteers have received any training in the proper use of PPE which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will ensure that all staff are provided with PPE training when they are initially hired and annually thereafter.
Please schedule PPE training with all staff and provide evidence that all staff have received PPE training by 7/17/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(11)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (11) A description of the ways in which the licensee will address resident behavioral expression as defined in Section 87101, Definitions, including resident assessments, care practices, and safety measures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of the Plan of Operation,there is no description of the ways in whick the licensee will address residents behavioral expressions as defined in Section 87101 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will create an addedum to the Plan of Operations to address how the facility will handle residents behavioral expressions as defined in Section 87101 by 7/17/25. If an extention is needed, it must be requested prior to the due date of the plan of correction.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as it was observed that the General Liability insurance for the period 3/1/24-3/1/25 had expired and per contact with the Insurance agent the insurance had expired on 8/31/2024 for non-payment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will contact an insurance agent to obtain the required general liability insurance of at least one million dollars ($1,000,000) per occurrence and three million dollars($3,000,000) in the total annual aggregate and provide a Certificate of Insurance naming the Department as a Cerfificate Holder by 7/17/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as the Licensee has not submitted Administrator documents to the Department for review of his qualifications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The LIcensee will submit the following documents to the Department for review: a current LIC501 Personnel Record, LIC508D Criminal Record Statement, a current LIC503 - Health Screen, a copy of the Administrator Certificate, a copy of the CPR/First aid training card, an updated LIC500 - Personnel Summary, LIC308 Designation of Facility Responsibilities and a Board Resolution. by 7/17/25.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 employee files reviewed that Alexander Otiashvili, Licensee/Administrator and Marina Martirosian, Staff do not have current CPR and first aid training. The last training expired on 6/17/25 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will ensure that all staff receive current CPR and first aid training. The Licensee will schedule CPR and first aid training for all staff that do not have current training and provide evidence of completion of training by 7/17/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as facility files do not have completed PRN Authorization Letters by their physicians for Resident #1 and Resident #2 for their PRN medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Licensee will contact Resident #1 and Resident #2 prescribing physician to obtain completed PRN Authorization Letters for their prn medications and maintain in their files by 7/17/25.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 4 residents did not have a completed admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will ensure that all residents have completed Admission Agreement on file. Licensee will schedule a meeting with the family/responsible person for Resident #1 to complete the Admission Agreement and maintain in the resident's file by 7/17/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 07/10/2025 08:00 PM - It Cannot Be Edited


Created By: Christine Yee On 07/10/2025 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interviews, the licensee did not comply with the section cited above as quarterly emergency drills are not being conducted as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will ensure that quarterly emergency drills are conducted quarterly and the drill are documented. The documentation should reflect the simulated disaster, date and time of the drill, who participated in the drills. A drill will be conducted and evidence sent to the Department by 7/17/25
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above per review of the Emergency Disaster Plan and Infection Control plans, they were last reviewed on 6/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee will ensure that the Emergency Disaster Plan and the Infection Control Plan are reviewed and updated as needed annually. Licensee will review both plans ands ubmit a written statement that the Plans was reviewed by 7/17/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385
VISIT DATE: 07/10/2025
NARRATIVE
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Report Continued from LIC 809...

The bathroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured at 115.8 degrees Fahrenheit at 3:50pm. Personal hygiene items were observed locked and inaccessible under the bathroom sink at the time of the visit.

BEDROOMS: There are three (3) total bedrooms in the facility; all bedrooms are designated for double occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

LAUNDRY ROOM: Washer and dryer were observed in a closet by the main hallway. The LPAs observed a closet with additional clean linens and towels for resident use.

BACKYARD: The LPAs observed an adequate amount of emergency food and water. Laundry detergent and cleaning supplies were observed in a locked cabinet and a locked shed at the time of the visit. The backyard has a shaded patio area with adequate furniture for residents’ use. All passageways were observed to be clear. The LPAs observed two (2) self-latching gates. However, one (1) gate was observed locked at the time of the visit. Technical Violation issued to remove lock from gate. There were no bodies of water noted at the time of the visit.

RECORDS: The LPAs reviewed resident records and staff records during today’s inspection.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with negative TB results, preplacement appraisal, and appraisal / current needs and services plan.

Per record review, 4 out of 4 residents did not have a preplacement appraisal on file, 3 out of 4 residents did not have a negative TB test result on file, 1 out of 4 residents did not have completed admissions agreement on file as it was missing signatures and dates from both resident and facility designee, and 2 out of 4 residents did not have a PRN authorization letter on file.

Two (2) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARE OF HEART
FACILITY NUMBER: 195850385
VISIT DATE: 07/10/2025
NARRATIVE
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Report Continued from LIC 809C...

Per record review, there is no evidence that the Administrator meets the educational requirements per regulations, staff providing care had first aid/cpr certification expire on 06/17/2025 and has not renewed it as of today, and 1 out of 2 staff is missing the health screening with negative TB test results,

MEDICATIONS: The LPAs conducted a medications review. Medications are centrally stored in a locked cabinet adjacent to the kitchen. Medications are being documented as they are received and appear to be administered as prescribed at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING/PLAN OF OPERATION: During today’s visit, the LPAs reviewed the facility's infection control plan. The staff does not have proper use of PPE training on file. The LPAs also reviewed the facility's emergency disaster plan, which was observed to be complete; however, both the infection control plan and emergency disaster plan are not being reviewed/updated annually since June 2023. Additionally, the LPAs did not observe any training logs for emergency disaster drills being conducted quarterly as per regulation. The Plan of Operation was observed to be missing section on how the facility will address residents with behavioral expressions and limited liability insurance was confirmed to have been cancelled since 08/30/2024 due to non-payment. Interviews with staff also revealed that the fire department was not notified of oxygen use by residents.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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